HomeMy WebLinkAbout1739A .-_...._..,. ��,,.,����ni��+rvutCLARAT�ON �� CEA�10/81.. ._.....APP����A"t�Ol�l�-FOR �L�S.rTEi�CFiL....f�iilYliT s t
� i hereby affirm ihat I hove o certificate,of consent to self � �
� � irnure�,or a certifictile oi Workers'Compensation�nsurance, COUNTY OP LOS ANGELES BUILDING AND SAfETY "
or a reriified�opy ihereof(Sec.3800,Lob.C.j ,_,____. .. . . .
.. ._..__._......
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55. WEST AM�RI. IN$
� P I�y No. Compa y_ � ...- e -.-.--. . .'.....- --��F�R APPLICANT TO Flll IN 10B
� _ _ . _....... .
-� �Certified copy is hereby furnished. EACH NO. FEE AD�RE55
New Reside tial Bldgs.B Pools
� Ceriifiied copy is filed with the munty 6ui�ding inspeo- 1 8 2-family,Sq.Ft. � 1 6�� � S — S � �OCALI7Y
� tion deportmenr. . Muki-family Sq.Ft. — NEARE51
ceoss sTC R
Residenfiol Swimming Pools OWNER ORCO�� GR�P
pate Applicanl .
. FIRM tJAMP+
CERT1fICATE OF EXEMPTION FROM WORKERS' Outlets:Rec?L�gh�1 Sw.l .IS 3 r � ���
COMPENSA71pN INSURANCE Firs�20 ADDRE55 $(Q T :"
(Thl��ectien neod nof ba eompl�fed if N�e work imolwd by Total No. Addi�ional ciTrORANGE, 92668 rei.No.558-9072
fhs permit is for one hundred dollars(5700)or less.) ptp.N CtiEGc �
� 1 certify thaf in the performante of�he wwk for which this APRICANT ,
permit is iuoed,I sholl not employ any person in eny monner
so as to become subject to the Workers'Compensation Laws. LigMing Fixtures First 20 qDDRESS
Tofal No. Additional
CIiY 7e1.No.
� Da�e ApplimM Pixed Appliances Not Over 1 HG PERMI7 �
���ICE TO APPLICANT: If, afrer making this Certificate of APP�ICANT
1 imptian, you should become subiect to ihe Woricers' Range_Heater_D.W. _ . . . �
� c.ompensation provisions of the Labor Code,yoa must fo��h- Oven _Dryer _W.M.— ADDRE55'L'L'L'Z �SAS AVE� STE �
�i witfi compiy with such provisions ortbis permii shal� be Top _Fnu —w.y.— oTvRIyERSTDE 92507 Tel.No. 7HB—
deemed reaoked. Hood _Fan _Other_ 911�
+ UCENSED CONTRACTORS DECLARATION D�s _Room Air Cond. — ���N'�� �
I hereby affirm Ihot I am licensed under provisians of Chopter 9 P' REG.NUMBER�'47SOS Class. C�10
j (commencing wi�h Seuion 700p)ot Division 3 of the Business DISTRICT NO. PROCESSE BY
� Power Apparotus 8 Lorge ApplianCes y
� and Professions Code,and my license is in fuil force and effect. �y
� Size 8 Type HP,KW,KVA,or KVAR �O a
} License Number�71Q� Lic Class C�10 Up fo 1 IncL FlNAi � V �
� Over 1 to 101nd. DATE � VALIDATION �
Comracfor €�€�ZT(ji£� ,�, —Date Over 10 to 50 incl. �
� O FINAL
I am exempt ander 5ec. Over 50�0 100 inc. BY uyi
� 8.8P.C.for this reason Over 100 �
Date: Se�vices,Sw6d.,MCC&Panelboards � �
� 0-2W Amp.Under 600 V
�� Signelure � 201-i000 Amp.Under 600 V �� i 3 9 A
- OOver 1000 Amp.or Ovcr 600 V .
Exemption for Reg.Maint Elect. �� � � � �z
� SINGtf FAMiIY Temp.Power Pole 8 Appurtenances
HOME OWNER-BU�LDER DKLARATION I • +H�.�O
� � Sign with One Branch Circuit
� }eby affirm ihot 1 am exempt irom the Con�rattor's license Addi�ional Si n Broncfi Circuih Z x
.3 for ihe following raoson(Section 703I.5,Bosiness and . 9 • a •� �, �Q c�
' Professions Code):
- ❑ f,as owner of ihe properly,wili do 1he work and the Misc Conduits 8 Conductors C 2.2��S�l
�� sirudure is not iMended or offered for sale (Sedion Othe�(See Complete Fee Schedulej_. �
704q,Business and Professions Code).
CONSTRUCTION LEND�NG AGENCY .
f hereby affirm ihal ihere ia a mnstrucfion lending ogenry for
ihe performance of�he work fo�which this permi�is issued PERMIi FEE (Sub-Total) ]fl�$ ���� � .. .
(Sec 3097.C�v.C.J. . �� ' . . .. . � .
� ..� . PtAN�f#fECKfNGfEE � --- - _.�.-. . .�_. � .
.. _. ... � ---- �
�tender's Namt� :. .. ... . . . _. . . . . .
� � , . . PERMti ISSUING FEf_.. . � .. � '
Lender's Address .
i eerlify thaf I have rea ihi opplicotion and stote thot 1he� TOTAI FEE 8���jQ. _
a6ore informarion is correu'1 agr to comply with all Counry
: ordinances and S�afe t ting fledricoi wiring,and � .
hareby�lufhorize rep p+al e of}hq Cou ty fo entar upon . -
t e ati ve-mentio �oper f fns Ec��ycp� SEE REVERSE FOR EXPLANATORY LANGUAGE _.
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